Coroner's Finding: Hill, James Fredrick

Contributing factors

• failure to recognise sepsis
• delayed diagnosis of ischaemic bowel
• failure to call MET team when clinically indicated
• delayed transfer to intensive care unit
• failure to investigate underlying cause of hypotension
• inappropriate modification of blood pressure parameters without documented reasoning
• culture of calling HMO instead of MET
• inadequate initial assessment and baseline investigations in emergency department
• poor communication between orthopaedic and medical teams
• staff unfamiliarity with MET escalation process
• inadequate staffing and heavy patient load affecting MET response capability

Coroner's recommendations

1. Recognition and treatment of sepsis protocols
2. Education on MET calling and functions
3. Modification of observation parameters and documentation of reasoning
4. Staff escalation procedures for patient concerns
5. Admission processes including documentation, comprehensive assessment, and investigation of underlying causes of falls
6. Baseline investigations including blood tests in emergency department
7. Investigation of unexplained hypotension
8. ICU transfer protocols for unstable patients